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The aftermath of Hurricane Katrina has placed a national spotlight on the shameful state of healthcare for America's poor. In the face of this highly publicized disaster, public health experts are more concerned than ever about persistent disparities that result from income and race.This book tells the story of one groundbreaking approach to medicine that attacks the problem by focusing on the wellness of whole neighborhoods. Since their creation during the 1960s, community health centers have served the needs of the poor in the tenements of New York, the colonias of Texas, the working class neighborhoods of Boston, and the dirt farms of the South. As products of the civil rights movement, the early centers provided not only primary and preventive care, but also social and environmental services, economic development, and empowerment.Bonnie Lefkowitz-herself a veteran of community health administration-explores the program's unlikely transformation from a small and beleaguered demonstration effort to a network of close to a thousand modern health care organizations serving nearly 15 million people. In a series of personal accounts and interviews with national leaders and dozens of health care workers, patients, and activists in five communities across the United States, she shows how health centers have endured despite cynicism and inertia, the vagaries of politics, and ongoing discrimination.

Cash transfers (CTs) are now high on the agenda of most governments in low-and middle-income countries. Within the field of health promotion, CTs constitute a healthy public policy initiative as they have the potential to address the social determinants of health (SDoH) and health inequalities. A systematic review was conducted to synthesise the evidence on CTs’impacts on SDoH and health inequalities in sub-Saharan Africa, and to identify the barriers and facilitators of effective CTs. Twenty-one electronic databases and the websites of 14 key organizations were searched in addition to grey literature and hand searching of selected journals for quantitative and qualitative studies on CTs’impacts on SDoH and health outcomes. Out of 182 full texts screened for eligibility, 79 reports that reported findings from 53 studies were included in the final review. The studies were undertaken within 24 CTs comprising 11 unconditional CTs (UCTs), 8 conditional CTs (CCTs) and 5 combined UCTs and CCTs. The review found that CTs can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration. The review further found that CTs modify intermediate determinants such as nutrition, dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage. In conjunction with their influence on SDoH, there is moderate evidence from the review that CTs impact on health and quality of life outcomes. The review also found many factors relating to intervention design features, macro-economic stability, household dynamics and community acceptance of programs that could influence the effectiveness of CTs. The external validity of the review findings is strong as the findings are largely consistent with those from Latin America. The findings thus provide useful insights to policy makers and managers and can be used to optimise CTs to reduce health inequalities. Les transferts de fonds (CT) figurent désormais parmi les priorités de la plupart des gouvernements des pays à revenu faible ou intermédiaire. Dans le domaine de la promotion de la santé, les CT constituent une saine initiative de politique publique puisqu’ils ont le potentiel de s’attaquer aux déterminants sociaux de la santé (DSS) et aux inégalités de santé. Une revue systématique a été réalisée dans le but de synthétiser les données sur les impacts des CT sur les inégalités de santé et les DSS en Afrique subsaharienne, et pour identifier les obstacles ainsi que les initiatives favorables à la mise en place de CT efficaces. Vingt et une bases de données électroniques et les sites Web de 14 organismes clés ont été consultés, en plus de la littérature grise et de la recherche manuelle de revues sélectionnées pour des études quantitatives et qualitatives sur les impacts des CT sur les DSS et les résultats de santé. Sur les 182 textes complets examinés pour leur recevabilité, 79 rapports présentant les résultats de 53 études ont été inclus dans l’examen final. Les études ont été menées dans le cadre de 24 transferts de fonds, à savoir, 11 transferts non conditionnels (UCT), 8 transferts conditionnels (CCT) ainsi que 5 UCT et CCT jumelés. L’étude a révélé que les CT peuvent être efficaces pour s’attaquer aux déterminants structurels de la santé tels que la pauvreté monétaire, l’éducation, la capacité de résilience des ménages, le travail des enfants, le capital social, la cohésion sociale, la participation civique et la déclaration des naissances. La revue a également révélé que les CT modifient les déterminants intermédiaires tels que la nutrition, la diversité alimentaire, le dénuement des enfants, les comportements sexuels à risque, la grossesse chez les adolescentes et les mariages précoces. En même temps que les transferts influent sur les DSS, des données de la revue tendent à prouver raisonnablement que les CT ont un impact sur la santé et la qualité de vie. La revue a également révélé de nombreux facteurs liés aux caractéristiques de conception de l’intervention, à la stabilité macroéconomique, à la dynamique des ménages et à l’acceptation par la collectivité des programmes susceptibles d’influer sur l’efficacité des CT. La validité externe des résultats de la revue est excellente, car les résultats sont en grande partie conformes à ceux de l’Amérique latine. Les résultats fournissent donc des indications utiles aux décideurs et aux gestionnaires et peuvent être utilisés pour optimiser les CT afin de réduire les inégalités en matière de santé. 现金转移支付 （CTs） 是目前许多中低收入国家政府的重要议 程。在健康促进领域, CTs是有利于健康的公共政策, 因为可 以影响健康的社会决定因素 （SDoH） 和健康不公平性。我们 进行了系统综述, 综合CTs对撒哈拉以南非洲地区SDoH和健康 不公平性的影响的证据, 寻找有效实施CTs的阻碍和促进因 素。检索21个电子数据库, 14个关键组织的网站, 检索灰色文 献, 手动检索选定的期刊, 查找关于CTs对SDoH和健康结局影 响的定量和定性研究。182篇文献进入全文筛选, 最终纳入79 篇文章, 报告了53个研究的发现。这些研究涉及24个CTs项目, 包括11个无条件CTs （UCTs）, 5个有条件CTs （CCTs） 和5个 UCTs与CCTs结合的项目。综述发现, CTs可有效影响健康的结 构决定因素, 例如贫困、教育、家庭恢复力、童工、社会资本 和社会凝聚力、公民参与, 以及出生登记。综述还发现, CTs 会改变中间决定因素, 例如营养、饮食多样性、儿童贫困、危 险性行为、青少年怀孕和早婚。除对SDoH的影响外, 本综述 还显示CTs对健康和生命结局质量的影响。综述还发现, 与干 预设计特征、宏观经济稳定性、家庭动态和社区接受程度相 关的许多因素会影响CTs的有效性。上述发现具有很强的外部 效度, 因为与拉丁美洲的研究发现大体上一致。本综述发现可 帮助决策者和管理者充分利用CTs来降低健康不平等。 Las transferencias en efectivo (TEs) están en una posición predominante en la agenda de la mayoría de los gobiernos de los países de ingresos bajos y medios. Dentro del campo de la promoción de la salud, las TEs constituyen una iniciativa de política pública saludable, ya que tienen el potencial para abordar los determinantes sociales de la salud (DSdS) y las desigualdades en la salud. Una revisión sistemática se realizó para sintetizar la evidencia de los impactos de las TEs sobre los DSdS y las desigualdades en el África sub-Sahariana, y para identificar las barreras y los facilitadores de las TEs efectivas. Se hicieron búsquedas en 21 bases de datos electrónicas y los sitios web de 14 organizaciones claves, en adición a la literatura gris y la búsqueda manual de revistas seleccionadas, para encontrar estudios cuantitativos y cualitativos sobre impactos de las TEs sobre los DSdS y sobre los resultados de salud. Además de 182 textos completos seleccionados como elegibles, 79 informes que informaron los resultados de 53 estudios se incluyeron en la revisión final. Los estudios se realizaron dentro de 24 TDs que comprenden 11 TEs incondicionales (TEIs), 8 TEs condicionales (TECs) y 5 TEls y TECs combinadas. La revisión encontró que las TDs pueden ser efectivas en la lucha contra los determinantes estructurales de la salud tales como la pobreza financiera, la educación, la capacidad de recuperación de los hogares, el trabajo infantil, el capital social y la cohesión social, la participación ciudadana, y el registro de nacimientos. La revisión encontró, además, que las TEs modifican los determinantes intermedios tales como la nutrición, la diversidad de la dieta, la privación del niño, los comportamientos sexuales de riesgo, el embarazo adolescente y el matrimonio precoz. En conjunción con su influencia en los DSdS, hay evidencia moderada del impacto de las TEs en los resultados de salud y calidad de vida. La revisión también encontró muchos factores relacionados con la intervención de las características de diseño, la estabilidad macroeconómica, la dinámica del hogar y la aceptación de la comunidad de programas que podrían influir en la eficacia de las TEs. La validez externa de los resultados de la revisión es fuerte ya que los hallazgos son ampliamente consistentes con los de América Latina. Los resultados proporcionan información útil a los formuladores de políticas y a los gestores y pueden ser usados para optimizar las TEs para reducir las desigualdades en salud.

Background Practitioners and decision makers in the medical and insurance systems need knowledge on the relationship between work exposures and burnout. Many burnout studies – original as well as reviews - restricted their analyses to emotional exhaustion or did not report results on cynicism, personal accomplishment or global burnout. To meet this need we carried out this review and meta-analyses with the aim to provide systematically graded evidence for associations between working conditions and near-future development of burnout symptoms. Methods A wide range of work exposure factors was screened. Inclusion criteria were: 1) Study performed in Europe, North America, Australia and New Zealand 1990–2013. 2) Prospective or comparable case control design. 3) Assessments of exposure (work) and outcome at baseline and at least once again during follow up 1–5 years later. Twenty-five articles met the predefined relevance and quality criteria. The GRADE-system with its 4-grade evidence scale was used. Results Most of the 25 studies focused emotional exhaustion, fewer cynicism and still fewer personal accomplishment. Moderately strong evidence (grade 3) was concluded for the association between job control and reduced emotional exhaustion and between low workplace support and increased emotional exhaustion. Limited evidence (grade 2) was found for the associations between workplace justice, demands, high work load, low reward, low supervisor support, low co-worker support, job insecurity and change in emotional exhaustion. Cynicism was associated with most of these work factors. Reduced personal accomplishment was only associated with low reward. There were few prospective studies with sufficient quality on adverse chemical, biological and physical factors and burnout. Conclusion While high levels of job support and workplace justice were protective for emotional exhaustion, high demands, low job control, high work load, low reward and job insecurity increased the risk for developing exhaustion. Our approach with a wide range of work exposure factors analysed in relation to the separate dimensions of burnout expanded the knowledge of associations, evidence as well as research needs. The potential of organizational interventions is illustrated by the findings that burnout symptoms are strongly influenced by structural factors such as job demands, support and the possibility to exert control.

Even though epidemiological evidence links specific workplace stressors to health outcomes, the aggregate contribution of these factors to overall mortality and health spending in the United States is not known. In this paper, we build a model to estimate the excess mortality and incremental health expenditures associated with exposure to the following 10 workplace stressors: unemployment, lack of health insurance, exposure to shift work, long working hours, job insecurity, work–family conflict, low job control, high job demands, low social support at work, and low organizational justice. Our model uses input parameters obtained from publicly accessible data sources. We estimated health spending from the Medical Expenditure Panel Survey and joint probabilities of workplace exposures from the General Social Survey, and we conducted a meta-analysis of the epidemiological literature to estimate the relative risks of poor health outcomes associated with exposure to these stressors. The model was designed to overcome limitations with using inputs from multiple data sources. Specifically, the model separately derives optimistic and conservative estimates of the effect of multiple workplace exposures on health, and uses optimization to calculate upper and lower bounds around each estimate, which accounts for the correlation between exposures. We find that more than 120,000 deaths per year and approximately 5%–8% of annual healthcare costs are associated with and may be attributable to how U.S. companies manage their work forces. Our results suggest that more attention should be paid to management practices as important contributors to health outcomes and costs in the United States. This paper was accepted by Dimitris Bertsimas, optimization .

Background The ways of life in the Amazon are diverse and not widely known. In addition, social inequities, large geographic distances and inadequate health care network noticeably limit access to health services in rural areas. Over the last decades, Brazilian health authorities have implemented fluvial mobile units (FMU) as an alternative to increase access and healthcare coverage. The aim of the study was to identify the strategies of access and utilization of primary health care (PHC) services by assessing the strengths and limitations of the healthcare model offered by the FMU to reduce barriers to services and ensure the right to healthcare. Methods Qualitative and ethnographic research involving participant observation and semi-structured interviews. Data collection consisted of interviews with users and health professionals and the observation of service organization and healthcare delivered by the FMU, in addition to the therapeutic itineraries that determine demand, access and interaction of users with healthcare services. Results Primary care is offered by the monthly locomotion of the FMU that serves approximately 20 rural riverside communities. The effectiveness of the actions of the FMU proved to be adequate for conditions such as antenatal care for low-risk pregnancy, which require periodic consultations. However, conditions that require continued attention are not adequately met through the organization of care established in the FMU. The underutilization of the workforce of community health workers and disarrangement between their tasks and those of the rest of the multi-professional team are some of the reasons pointed out, making the healthcare continuity unfeasible within the intervals between the trips of the FMU. From the users’ perspective, although the presence of the FMU provides healthcare coverage, the financial burden generated by the pursuit for services persists, since the dispersed housing pattern requires the locomotion of users to reach the mobile unit services as well as for specialized care in the urban centers. Conclusions The implementation of the FMU represents an advance in terms of accessibility to PHC. However, the organization of their activity uncritically replicates the routines adopted in the daily routine of health services located in urban spaces, proving to be inadequate for providing healthcare strategies capable of mitigating social and health inequalities faced by the users.

Background Although most Latin American and the Caribbean (LAC) countries made important progress in maternal and child health indicators from the 1990s up to 2010, little is known about such progress in the last decade. This study aims at documenting progress for each country as a whole, and to assess how within-country socioeconomic inequalities are evolving over time. Methods We identified LAC countries for which a national survey was available between 2011–2015 and a second comparable survey in 2018–2020. These included Argentina, Costa Rica, Cuba, the Dominican Republic, Guyana, Honduras, Peru, and Suriname. The 16 surveys included in the analysis collected nationally representative data on 221,989 women and 152,983 children using multistage sampling. Twelve health-related outcomes were studied, seven of which related to intervention coverage: the composite coverage index, demand for family planning satisfied with modern methods, antenatal care (four or more visits and eight or more visits), skilled attendant at birth, postnatal care for the mother and full immunization coverage. Five additional impact indicators were also investigated: stunting prevalence among under-five children, tobacco use by women, adolescent fertility rate, and under-five and neonatal mortality rates. For each of these indicators, average annual relative change rates were calculated between the baseline and endline national level estimates, and changes in socioeconomic inequalities over time were assessed using the slope index of inequality. Results Progress over time and the magnitude of inequalities varied according to country and indicator. For countries and indicators where baseline levels were high, as Argentina, Costa Rica and Cuba, progress was slow and inequalities small for most indicators. Countries that still have room for improvements, such as Guyana, Honduras, Peru and Suriname, showed faster progress for some but not all indicators, although also had wider inequalities. Among the countries studied, Peru was the top performer in terms of increasing coverage and reducing inequalities over time, followed by Honduras. Declines in family planning and immunization coverage were observed in some countries, and the widest inequalities were present for adolescent fertility and antenatal care coverage with eight or more visits. Conclusions Although LAC countries are well placed in terms of current levels of health indicators compared to most low- and middle-income countries, important inequalities remain, and reversals are being observed in some areas. More targeted efforts and actions are needed in order to leave no one behind. Monitoring progress with an equity lens is essential, but this will require further investment in conducting surveys routinely.

Efforts to promote equity in healthcare involve implementing policies and programs that address the root causes of healthcare disparities and promote equal access to care. One such program is the public social healthcare protection schemes. However, like many other developing countries, Tanzania has low health insurance coverage, hindering its efforts to achieve universal health coverage. This study examines the role of equity in public social healthcare protection and its effects on household healthcare financing in Tanzania. The study used secondary data collected from the National Bureau of Statistics' National Panel Survey 2020/21 and stratified households based on their place of residence (rural vs. urban). Moreover, the logit regression model, ordered logit, and the endogenous switching regression model were used to provide counterfactual estimates without selection bias and endogeneity problems. The results showed greater variations in social health protection across rural and urban households, increasing disparities in health outcomes between these areas. Rural residents are the most vulnerable groups. Furthermore, education, income, and direct healthcare costs significantly influence equity in healthcare financing and the ability of households to benefit from public social healthcare protection schemes. To achieve equity in healthcare in rural and urban areas, developing countries need to increase investment in health sector by reducing the cost of healthcare, which will significantly reduce household healthcare financing. Furthermore, the study recommends that social health protection is an essential strategy for improving fair access to quality healthcare by removing differences across households and promoting equality in utilizing healthcare services.

Self-identified race/ethnicity is largely used to identify, monitor, and examine racial/ethnic inequalities. A growing body of work underscores the need to consider multiple dimensions of race – the social construction of race as a function of appearance, societal interactions, institutional dynamics, stereotypes, and social norms. One such multidimensional measure is socially-assigned race, the perception of one’s race by others, that may serve as the basis for differential or unfair treatment and subsequently lead to deleterious health outcomes. We conducted a scoping review to systematically appraise the socially-assigned race and health literature. A systematic search of the PubMed, Web of Science, 28 EBSCO databases and 24 Proquest databases up to September 2019 was conducted and supplemented by a manual search of reference lists and grey literature. Quantitative and qualitative studies that examined socially-assigned race and health or health-related outcomes were considered for inclusion. Eighteen articles were included in the narrative synthesis. Self-rated health and mental health were among the most frequent outcomes studied. The majority of studies were conducted in the United States, with fewer studies conducted in New Zealand, Canada, and Latin America. While most studies demonstrate a positive association between social assignment as a disadvantaged racial or ethnic group and poorer health, some studies did not document an association. We describe key conceptual and methodological considerations that should be prioritized in future studies examining socially-assigned race and health. Socially-assigned race can provide additional insight into observed differential health outcomes among racial/ethnic groups in racialized societies based upon their lived experiences. Studies incorporating socially-assigned race warrants further investigation and may be leveraged to examine nuanced patterns of racial health advantage and disadvantage.

The presumed global consensus on achieving Universal Health Coverage (UHC) masks crucial issues regarding the principles and politics of what constitutes “universality” and what matters, past and present, in the struggle for health (care) justice. This article focuses on three dimensions of the problematic: 1) we unpack the rhetoric of UHC in terms of each of its three components: universal, health, and coverage; 2) paying special attention to Latin America, we revisit the neoliberal coup d’état against past and contemporary struggles for health justice, and we consider how the current neoliberal phase of capitalism has sought to arrest these struggles, co-opt their language, and narrow their vision; and 3) we re-imagine the contemporary challenges/dilemmas concerning health justice, transcending the false technocratic consensus around UHC and re-infusing the profoundly political nature of this struggle. In sum, as with the universe writ large, a range of matters matter: socio-political contexts at national and international levels, agenda-setting power, the battle over language, real policy effects, conceptual narratives, and people’s struggles for justice.

Background Since the early 1990s, Colombia has made great strides in extending healthcare coverage to its population. In order to measure the impact of these efforts, it is important to assess whether the introduction of universal health coverage has translated into equitable access to healthcare in the country, particularly for the elderly. Thus, in this study we assessed the inequality in utilization of health services among elderly patients in Colombia. In addition, we identified the determinants of healthcare utilization. Methods We analyzed the 2015 Colombian health, well-being and aging study (SABE). To classify determinants of healthcare use into predisposing, enabling and need factors, we employed the Anderson framework of healthcare utilization. Use of outpatient, inpatient and preventive health services constituted the dependent variables. We performed multivariate logistic regressions, estimated concentration indexes (CI) and performed decomposition analyses of the CIs to determine the contribution of various determinants to inequality of healthcare utilization. Results The study sample included 23,694 adults over 60-years-old. Wealth quintile, urban dwelling, health insurance type and multimorbidity predicted the utilization of all types of healthcare services except for hospitalization. Aside from inpatient care, pro-rich inequality in utilization of healthcare services was present. Wealth quintile and type of health insurance were the largest contributors to pro-rich inequality in use of preventive services. Conclusions While there has been progress in health insurance coverage for the elderly in Colombia, there are still equality challenges in the delivery of healthcare, especially for preventive and outpatient care. These inequalities are driven by individual characteristics such as wealth, urban residence, type of health insurance carried, and presence of multimorbidity. To address this issue, the Colombian health system should extend health insurance coverage to uninsured populations, as well as reduce barriers of access to healthcare services among poorest and the rural population receiving subsidized insurance.